Development of a Model to Identify Febrile Children at Low Risk for Multisystem Inflammatory Syndrome.

OBJECTIVES: The case definition for multisystem inflammatory syndrome in children (MIS-C) is broad and encompasses symptoms and signs commonly seen in children with fever. Our aim was to identify clinical predictors that, independently or in combination, identify febrile children presenting to the emergency department (ED) as low risk for MIS-C. METHODS: We conducted a retrospective single-center study of otherwise healthy children 2 months to 20 years of age presenting to the ED with fever and who had a laboratory evaluation for MIS-C between April 15, 2020, and October 31, 2020. We excluded children with a diagnosis of Kawasaki disease. Our outcome was an MIS-C diagnosis defined by the Centers for Disease Control and Prevention criteria. We conducted multivariable logistic regression analyses to identify variables independently associated with MIS-C. RESULTS: Thirty-three patients with and 128 patients without MIS-C were analyzed. Of those with MIS-C, 16 of 33 (48.5%) had hypotension for age, signs of hypoperfusion, or required ionotropic support. Four variables were independently associated with the presence of MIS-C; known or suspected SARS CoV-2 exposure (adjusted odds ratio [aOR], 4.0; 95% confidence interval [CI], 1.4-11.9) and the following 3 symptoms and signs: abdominal pain on history (aOR, 4.8; 95% CI, 1.7-15.0), conjunctival injection (aOR, 15.2; 95% CI, 5.4-48.1), and rash involving the palms or soles (aOR, 12.2; 95% CI, 2.4-69.4). Children were at low risk of MIS-C if none of the 3 symptoms or signs were present (sensitivity 87.9% [95% CI, 71.8-96.6]; specificity 62.5% [53.5-70.9], negative predictive value 95.2% [88.3-98.7]). Of the 4 MIS-C patients without any of these 3 factors, 2 were ill-appearing in the ED and the other 2 had no cardiovascular involvement during their clinical course. CONCLUSIONS: A combination of 3 clinical symptoms and signs had moderate to high sensitivity and high negative predictive value for identifying febrile children at low risk of MIS-C. If validated, these factors could aid clinicians in determining the need to obtain or forego an MIS-C laboratory evaluation during SARS-CoV-2 prevalent periods in febrile children.

When to stop medication in juvenile idiopathic arthritis.

PURPOSE OF REVIEW: Disease-modifying antirheumatic drugs (DMARDs) have dramatically improved patient outcomes in juvenile idiopathic arthritis (JIA). However, these medications may also result in physical, psychologic, and economic burden, which must be balanced with risk of flare off treatment. Although some children remain in remission after medication discontinuation, evidence is sparse for if, when, and how medications should be de-escalated once achieving clinically inactive disease (CID). We review the data on medication discontinuation and the role of serologic and imaging biomarkers in JIA. RECENT FINDINGS: The literature uniformly supports early biologic DMARD initiation, although the optimal timing and strategy for medication withdrawal in patients with sustained CID remains unclear. In this review, we present the current data on flare frequency and time to flare, clinical factors associated with flare, and recapture data for each JIA category. We also summarize the current knowledge on the role of imaging and serologic biomarkers in guiding these treatment decisions. SUMMARY: JIA is a heterogenous disease for which prospective clinical trials are needed to address the question of when, how, and in whom to withdraw medication. Research investigating the roles of serologic and imaging biomarkers may help improve the ability to ascertain which children can successfully de-escalate medications.

Assessment of a Fruit and Vegetable Prescription Program in the Northern Manhattan Community.

PURPOSE: This study aimed to assess whether produce prescription redemption was associated with food insecurity (FI), sociodemographics, and nutrition-related health measures, and to identify factors affecting participation. DESIGN: Retrospective, cross-sectional study. Patients, equally divided between groups who redeemed and did not redeem prescriptions, completed a follow-up survey. SETTING: Northern Manhattan, NY. SUBJECTS: 242 patients referred to Nutrition at an academic medical center between June and November 2019. INTERVENTION: All patients referred to Nutrition received prescriptions for produce at local Greenmarkets (patients with FI received $20; other patients received $10). MEASURES: We assessed patient satisfaction and factors impacting participation. Sociodemographics and nutrition-related health measures were extracted from medical records. ANALYSIS: The χ2 test for categorical data and Student's t-test for continuous variables. RESULTS: Prescription redeemers were significantly more likely to be very satisfied with the program (P < .001), have FI (P < .01), and have elevated hemoglobin A1C than non-redeemers (6.3 vs 5.5%, P < .001). Distance, time constraints, and forgetting or losing the prescription were common barriers, while convenience and valuing healthy eating facilitated redemption. CONCLUSION: Higher FI and worse hemoglobin A1c in patients who redeemed prescriptions suggests that our program reaches the target audience: patients needing food assistance and a healthier diet. Awareness of barriers offers areas for improvement. This provides a feasible model for hospital investment to increase access to produce to improve health and health equity.

The potential role of Colchicine in preventing coronary vascular disease in childhood-onset lupus: a new view on an old drug.

BACKGROUND: Patients with systemic lupus erythematous have a significantly increased risk of cardiovascular disease, which is not fully explained by traditional cardiovascular disease risk factors. Despite increasing life expectancy in patients with systemic lupus erythematous, mortality due to cardiovascular disease, the major cause of death in these patients, has not changed. Children with lupus suffer from more aggressive disease compared to their adult counterparts, and there is a growing concern for their increased risk of cardiovascular disease as they age. BODY: There is an unmet need for therapies to address the increased risk of cardiovascular disease in childhood-onset lupus. Colchicine has many anti-inflammatory and cardiovascular protective properties, including inhibition of IL-1ß and IL-18 activity, key proinflammatory cytokines that are predictive of future adverse cardiovascular events. In the Colchicine Cardiovascular Outcomes Trial (COLCOT), colchicine was recently found to have significant benefit with minimal risk in adults with previous myocardial infarction for prevention of secondary vascular disease. While adult studies are promising, no studies have been conducted in pediatric patients to investigate colchicine's potential for cardiovascular protection in children and adolescents with lupus. CONCLUSIONS: Studies investigating colchicine's potential role for cardiovascular protection are needed in pediatric patients with systemic lupus erythematous.

Discriminating Multisystem Inflammatory Syndrome in Children Requiring Treatment from Common Febrile Conditions in Outpatient Settings.

OBJECTIVES: To examine whether patients with multisystem inflammatory syndrome in children (MIS-C) demonstrated well-defined clinical features distinct from other febrile outpatients, given the difficulties of seeing acute care visits during the severe acute respiratory syndrome coronavirus 2 pandemic and the risks associated with both over- and underdiagnosis of MIS-C. STUDY DESIGN: This case-controlled study compared patients diagnosed with and treated for MIS-C at a large urban children's hospital with patients evaluated for fever at outpatient acute care visits during the peak period of MIS-C. Symptomatology and available objective data were extracted. Comparisons were performed using t tests with corrections for multiple comparisons, and multivariable logistic regression to obtain ORs. RESULTS: We identified 44 patients with MIS-C between April 16 and June 10, 2020. During the same period, 181 pediatric patients were evaluated for febrile illnesses in participating outpatient clinics. Patients with MIS-C reported greater median maximum reported temperature height (40°C vs 38.9, P < .0001), and increased frequency of abdominal pain (OR 12.5, 95% CI [1.65-33.24]), neck pain (536.5, [2.23-129,029]), conjunctivitis (31.3, [4.6-212.8]), oral mucosal irritation (11.8, [1.4-99.4]), extremity swelling or rash (99.9, [5-1960]), and generalized rash (7.42, [1.6-33.2]). Patients with MIS-C demonstrated lower absolute lymphocyte (P < .0001) and platelet counts (P < .05) and greater C-reactive protein concentrations (P < .001). CONCLUSIONS: Patients treated for MIS-C due to concern for potential cardiac injury show combinations of features distinct from other febrile patients seen in outpatient clinics during the same period.

Exploring the Gap: Food Insecurity and Resource Engagement.

BACKGROUND: Pediatric health care institutions are increasingly implementing food insecurity (FI) screens, but there is limited information about participant interest in referral and engagement with resources provided. METHODS: In this descriptive cross-sectional study, we recruited participants from a consecutive sample of adult caregivers arriving with pediatric patients in the emergency department at an urban, freestanding children's hospital. Caregivers completed a validated, 2-question screen for FI. All participants received a list of food access resources. Direct referral to a partnered community food resource agency was offered to those who screened positive for FI; that agency completed a phone call to the participant for resource provision within 2 weeks. RESULTS: Among the 1818 participants recruited, 20.6% (375) screened positive for FI, consistent with the area's reported child FI rate. Of those who screened positive, 54.9% (206) opted to receive a direct-referral via phone call to a food resource agency, and 35.9% (74) of these were reached by phone. About 31.1% (23) of those contacted were no longer interested in food resource referrals, 10.8% (8) were signed up for the Supplemental Nutrition Assistance Program, and 59.5% (44) were referred to local food pantries. CONCLUSIONS: Through hospital-community partnership in an initial attempt to screen and offer direct-referral for FI, we elicited considerable interest among families for connection to resource agencies. However, there was a substantial gap between referral acceptance and ultimate connection with the resource agency stemming from 2 major sources: inability to re-contact and loss of interest after contact.

mJustice: Preliminary Development of a Mobile App for Medical-Forensic Documentation of Sexual Violence in Low-Resource Environments and Conflict Zones.

Digital health development and use has been expansive and operationalized in a variety of settings and modalities around the world, including in low- and middle-income countries. Mobile applications have been developed for a variety of health professionals and frontline health workers including physicians, midwives, nurses, and community health workers. However, there are no published studies on the development and use of digital health related to human rights fieldwork and to our knowledge no mobile health platforms exist specifically for use by frontline health workers to forensically and clinically document sexual violence. We describe a participatory development and user design process with Congolese end-users of a novel human rights app for clinicians intended to standardize the documentation of sexual violence evidence for forensic and legal purposes, called MediCapt. The app, yet to be launched and still in the future proofing phase, has included several development phases: (1) initial needs assessment conducted in 2011, (2) prototype development and field-testing in 2014 with 8 Congolese physicians, (3) prototype refinement and field-testing in 2015 with 9 clinicians. Feedback from the first field-testing phase was incorporated into the design of the second prototype; key features that were added to MediCapt include the ability for users to take photographs and draw on a pictogram to include as part of the evidence package, as well as the ability to print a form with the completed data. Questionnaires and key-informant interviews during the second and third field-testing phases revealed overall positive attitudes about MediCapt, but multiple perceived and actual barriers to implementation were identified, from personal behaviors, such as individual clinicians' comfort with new technology, to more systemic and infrastructure factors, such as strong cultural preferences for print documentation of evidence and limited Internet connectivity. Next phases of development include consideration of patients' acceptance of this technology, how it actually fits in the clinical workflow, and testing of how to transfer the collected evidence to law enforcement and legal authorities. Ultimately, we plan on conducting a robust evaluation to assess effectiveness of the app on medical, legal, and human rights outcomes. We believe our experience of collecting data that will potentially serve as legal evidence broadens the traditional scope of digital health and crosses a wide range of fields including medical, technological, legal, and ethical, and thus propose refining and defining this unique field of exploration as mobile justice, or mJustice.